A rare case of metastatic malignant phyllodes tumor with osteosarcomatous differentiation presenting with intestinal obstruction

Phyllodes tumors (PTs) are uncommon biphasic breast neoplasms constituting 0.5 to 1.0% of all breast tumors. Malignant PTs form a very small proportion of these and may metastasize, especially to the lungs and bones. Aggression and metastatic potential are accentuated in tumors exhibiting heterologous differentiation. Metastases to the gastrointestinal tract (GIT) have seldom been reported and are often confined to a segment of the digestive tract. In the absence of relevant clinical history, such patients presenting with gastrointestinal symptoms can lead to diagnostic perplexities. We report a unique case of a malignant PT with extensive osteosarcomatous differentiation and widespread metastases to the GIT.

The occult rheumatic scourge: A clinicopathological analysis of missed rheumatic heart disease

Aims: To study the clinical and pathological manifestations of missed cases of rheumatic heart disease (RHD) and postulate possible reasons behind a missed diagnosis. Materials and Methods: Retrospective 20-year (2000–2019) autopsy data of chronic RHD were reviewed and patients, in whom the valvular deformities had been incidental autopsy findings, were selected. The clinical details of these patients were correlated with the morphology of the affected valves. On this pathological analysis, the patients were assigned to a category of subtle or significant valvular deformity. By clinically correlating, the latter group was subdivided into clinically misdiagnosed, clinically undiagnosed, and sudden cardiac death. Statistical Analysis: Nil. Results: Among the 475 cases of chronic RHD identified at autopsy in the study period, the disease was diagnosed incidentally in 69 patients (14.5%). Significant valvular deformity was noted in 61 cases while the other 8 cases had subtle valvular deformity. The most common cause of death was cardiac failure in 39 out of 69 patients (56%). Eleven (16%) patients had experienced sudden cardiac death. Among the undiagnosed cases, 5 (7%) of them had a diagnosis of non-rheumatic cardiac disease, while the other 14 (20.5%) patients had overwhelming non-cardiac diseases. Conclusions: Our study indicates that mortality and morbidity due to RHD are underdetermined. The patients remain undiagnosed due to either insignificant valvular involvement, clinically silent in the presence of significant valvular deformity, presence of other overwhelming diseases or misdiagnosis partly due to the resemblance with the other pathologies.

Thymectomy for myasthenia gravis: A pathological analysis

Background: Myasthenia gravis (MG) is a prototypic T-cell-dependent antibody-mediated autoimmune disease that leads to ocular or generalized muscular weakness. The disease is most commonly caused by antibodies to the acetylcholine receptors, often with underlying thymic pathology. Aims: This study is aimed at analyzing the pathological spectrum of the excised thymuses in patients with myasthenia. Materials and Methods: This was a retrospective 10-year study of 68 thymectomy specimens performed as a part of the treatment of patients with MG. Statistical Analysis: Nil. Results: There were 47 males and 21 females (male to female ratio of 2.2:1) with a mean age of 41 years. Only three patients presented with ocular myasthenia. The thymus was normal in 9 patients (13.2%) and atrophic in 17 patients (25%). Follicular hyperplasia and thymomas were seen in 6 and 36 patients, respectively. Conclusion: The thymectomies performed in patients of MG had a fairly variable spectrum on histology; the thymic tumors were predominantly of the cortical phenotype.

Disseminated epithelial cancers—An autopsy analysis

Background: Cancer is one of the leading causes of death due to noncommunicable diseases worldwide. Despite increasing public awareness and availability of sophisticated imaging techniques, some cancers evade clinical diagnosis and/or are incidentally encountered at autopsies, often with dissemination. Aims: The present study evaluated the disseminated epithelial cancers at autopsy. Materials and Methods: This is a retrospective observational 5-year autopsy analysis of disseminated epithelial cancers performed at a tertiary-care hospital. The cases were categorized as (1) clinically diagnosed malignancy, known primary; (2) clinically diagnosed malignancy, unknown primary; and (3) clinically undiagnosed malignancy. Statistical Analysis: Nil. Results: Dissemination was identified in 66 (57.9%) of the 114 patients with epithelial malignancies. There were 29 patients (43.9%) in category 1, 26 patients (39.4%) in category 2, and 11 patients (16.7%) in category 3, majority of whom were women (38 patients, 57.6%). When all categories were considered together, lung and colorectal carcinomas were the commonest cancers seen in 13 (19.7%) and 8 (12.1%) patients, respectively, in both men and women. Majority of the patients (43 cases, 65.2%) had symptoms produced by metastases, which were the sole manifestations in 13 patients (19.7%). Lungs and liver were the common metastatic sites. Conclusions: Cancerous dissemination continues to be a major cause of morbidity and mortality even after considerable improvements in the surgical or nonsurgical treatment modalities. An autopsy study can provide important clinical insights in retrospect.

Multifocal Epstein–Barr virus-associated miliary post-transplant smooth muscle tumors

Epstein–Barr virus (EBV) promotes the development of undifferentiated carcinomas of the upper aerodigestive tract and different types of lymphomas. This ability of tumorigenesis is heightened in many immunocompromised patients who have an increased incidence of lymphoproliferative disorders. The virus also induces smooth muscle proliferation, and those occurring following transplantation are designated as EBV-associated post-transplant smooth muscle tumors. We report multifocal miliary-sized leiomyomas in the lungs in a renal transplant recipient as an incidental finding.

Unusual rib tumor: parosteal lipoma with extensive osteochondromatous metaplasia.

Lipomas of the bone usually occur in the long bones and are seen in the fifth to seventh decade of life. Rib lipomas are rare and those having parosteal location are even rarer. We report a case of parosteal lipoma of the rib in a young male with some unique features. This is the fifth case of its kind to be reported in literature.

Cardiovascular involvement in systemic lupus erythematosus: an autopsy study of 27 patients in India.

BACKGROUND: Although cardiovascular disease (CVD) is recognized as a leading cause of death in patients with systemic lupus erythematosus (SLE) in western countries, there is hardly any data regarding Indian subjects with SLE. AIMS: To determine the incidence of cardiac abnormalities and vascular lesions at autopsy and to assess their contribution to the mortality in patients with SLE. SETTINGS AND DESIGN: Retrospective retrieval of reports of autopsies performed on 35 patients with SLE over a 11 year period and analysis of 27 cases with cardiac and/or vascular lesions. MATERIALS AND METHODS: Gross and microscopic features in 27 autopsies were analyzed with special attention to the heart and the vasculature of all organs. Findings were correlated with clinical features and ante-mortem investigations. Their contribution towards mortality was assessed. RESULTS: Valvar lesions were the commonest cardiac lesions noted with non-bacterial thrombotic endocarditis in nine (33.33%), valvar thickening in two (7.41%), Libman-Sacks endocarditis and infective endocarditis in one (3.70%) each. Myocarditis and myocardial scarring were seen in 10 (37.03%) and seven (25.92%) cases, respectively. Fibrinous pericarditis was noted in seven (25.92%). Thromboses/embolism, vasculitis and severe coronary atherosclerosis were seen in nine (33.33%), five (18.52%) and one (3.70%) subjects, respectively. Renal disease [13, 48.14%] and cardiovascular manifestations [8, 29.62%] were the leading causes of death in our patient population. CONCLUSION: CVD contributes significantly to the mortality in patients with SLE in India. It is second only to renal disease in this regard.

A study of sutopsy findings in 62 cases of leptospirosis in a metropolitan city in India.

BACKGROUND: Leptospirosis is an important sporadic zoonotic disease caused by the spirochete Leptospira icterohaemorrhagiae . The disease becomes a major public health problem, particularly during the monsoon months. MATERIALS AND METHODS: Analysis of autopsy findings of 62 cases of clinically suspected leptospirosis was carried out to identify the pathology and determine the cause of death. RESULTS: Most patients were young males who presented with fever, breathlessness, haemoptysis, bleeding, oliguria and icterus. They died after a brief stay in hospital. A post-mortem diagnosis of leptospirosis was made on the basis of characteristic organ findings, aided by results of serology, Levaditi's staining and / or immunohistochemistry (IHC) on kidney sections. Massive intra-alveolar haemorrhage (48 cases), acute interstitial nephritis and / or acute tubular necrosis (45 cases) and myocarditis (24 cases) were the main autopsy findings. Haemorrhage in various organs like the heart, gastrointestinal tract, brain, pancreas and adrenals were also seen. Thirty of 54 kidney sections were positive for leptospiral antigens by IHC. There was extensive haemorrhages in the lungs in 48 (77%) cases and that was the cause of death in most of these cases. CONCLUSION: Bleeding into various tissues and organs is the main finding noted in this study. The post-mortem examination of patients dying of leptospirosis revealed that pulmonary haemorrhage was the cause of death in most individuals.

Sino-nasal epithelial tumours: a pathological study of 69 cases.

BACKGROUND: Epithelial neoplasms are uncommon lesions affecting the sino-nasal tract. There are hardly any reports in the Indian literature. AIM: To study the incidence, mode of presentation and histological types of sino-nasal epithelial tumours in the surgical pathology material. SETTING AND DESIGN: Retrospective retrieval of all sino-nasal tumours and analysis of epithelial tumours. MATERIALS AND METHODS: All sino-nasal epithelial tumours, biopsied or surgically excised over a period of ten years, were studied. The tumours were classified as benign or malignant. The histology was correlated with the clinical presentation and investigations. RESULTS: In ten years, there were 120 sino-nasal tumours representing 0.14% of all the surgical specimens received. Sixty-nine epithelial tumours (59.2%) outnumbered the non-epithelial tumours and were diagnosed on the basis of histopathology. Twenty were benign and 49 malignant; occurring predominantly in males. Benign lesions included four squamous papillomas and 16 inverted papillomas, with recurrence in three inverted papillomas (21%). Squamous cell carcinomas were the commonest among malignant tumours and four of these were associated with inverted or cylindrical cell papilloma. The second most frequent malignant tumour was adenoid cystic carcinoma with eight cases. Other rare types included the variants of squamous carcinoma, adenocarcinomas of the non-enteric type, muco-epidermoid carcinoma and undifferentiated carcinomas. CONCLUSION: Sino-nasal epithelial tumours are rare lesions, with male preponderance. Inverted papillomas and squamous cell carcinomas are the most frequent neoplasms.

Invasive pulmonary aspergillosis: A study of 39 cases at autopsy.

BACKGROUND: Aspergillus is a common cause of invasive mycosis, especially in immunocompromised or immunosuppressed individuals. AIMS: To study the incidence of invasive pulmonary aspergillosis and evaluate the predisposing factors and clinico-pathological manifestations. SETTINGS AND DESIGN: Retrospective analysis of autopsy material from a tertiary care hospital. MATERIAL AND METHODS: All autopsies performed over a 12-year period were reviewed and cases with invasive aspergillosis were analysed with respect to their clinical presentation, predisposing factors, gross and histological features, complications and causes of death. RESULTS: Among a total of 20475 autopsies performed in 12 years, 39 patients (0.19 %) had invasive pulmonary aspergillosis. There were 28 males and 11 females. Their ages ranged from five months to 67 years. Dyspnoea, fever, cough with mucopurulent expectoration, chest pain and haemoptysis were commonly encountered symptoms. Forty-one per cent of the patients had no respiratory symptoms. Fungal aetiology was not entertained clinically in any of the patients. The major underlying conditions were prolonged antibiotic therapy, steroid therapy, and renal transplantation, often associated with underlying lung diseases. Pneumonia, abscesses, vascular thrombosis and infarction were common findings at autopsy. Antecedent tuberculosis, mucormycosis, Pneumocystis carinii pneumonia and Cytomegalovirus infection were also present. In most cases, death was related to extensive pulmonary involvement or fungal dissemination. CONCLUSION: A diagnosis of invasive pulmonary aspergillosis should always be borne in mind whenever one is dealing with recalcitrant lung infections even with subtle immunosuppression. Radiological investigations and serologic markers can be utilised for confirmation and prompt therapy.